해외 증례(Japan) Scattered Tiny Whitish Protrusions in the Stomach Are a Clue to the Diagnosis of Autoimmune Gastritis

관리자
2023-11-13
조회수 64

Acta Med. Okayama, 2023 Vol. 77, No. 1, pp. 75-80


<Case 1, 17년간 annual endoscopy>

52세, 여성 (Fig. 1)

P/Hx: appendectomy, tonsillectomy, hyperthyroidism

Figure 1. Endoscopic images of Case 1 at the age of 52 years. Although she was diagnosed as having H. pylori-associated atrophic gastritis, retrospective re-evaluation of the endoscopy images revealed atrophy in the fornix (A) and corpus (B). This was in contrast to the common involvement of the antrum (C) in H. pylori-associated gastritus. 

* 62세: Bx (H. pylori 양성),UBT (positive, 4.8‰ (normal range, 0-2.4)) 

first-line (rabeprazole, amoxicillin, and clarithromycin) -> second-line (rabeprazole, amoxicillin, and metronidazole) 치료 하였으나, UBT (positive, 9.1‰) 

* 65세: UBT (positive, 84.4‰), H. pylori stool Ag (negative) 

Third-line (vonoprazan, amoxicillin, sitafloxacin) -> 4개월 뒤 UBT (positive, 2.7‰), 하지만 upper limit가 2.4 이므로 일단 제균은 되었을 것으로 생각하고 치료는 중단 함.

* 69세: EGD (Fig 2)

Figure 2. Endoscopic images of Case 1 at the age of 69 years. Scattered minute whitish protrusions were observed in the gastric fundus (A-C, arrows; A, white light image; B, linked color imaging after indigo carmine dye spraying; C, blue laser imaging). There was corpus-predominant atrophy (D), while the antrum was less affected (E). 

* Pathological evaluation: chromogranin A staining (endocrine cell hyperplasia forming linear clusters and micro-nests)

* LAB: positive (intrinsic factor antibodies & parietal cell antibodies)

Pepsinogen I level: 4.3 ng/mL (normal, 28-100 ng/ml), Pepsinogen II level: 7.2 ng/mL (normal)

Pepsinogen I/II ratio: 0.6

* VitaB12: < 100 pg/mL 


<Case 2, 9년간 annual endoscopy>

38세, 여성

P/Hx: Graves' disease (PTU 복용중)

Health check-up 중 elevated lesion에 대한 평가 위해 refered.

Reddish polyp in her gastric corpus (Fig. 3) - hyperplastic polyp (annual f/u)

Figure 3. Endoscopic images of Case 2 at the age of 38 years. A reddish hyperplastic polyp was observed in the gastric corpus (A). Although atrophy of the gastric mucosa was not initially noticed, re-evaluation of the endoscopic images revealed fornix- and corpus dominant atrophy (B) and less involvement of the antrum (C). 

* Anti-H. pylori IgG (positive) -> vonoprazan, amoxicillin, clarithromycin -> UBT(-)

* 47세 EGD에서 small flat white lesion in the gastric angle -> pathologic result: signet ring cell carcinoma -> ESD (sucessfully)

* 치료 6개월뒤 EGD: 

- Scattered tiny whitish protrusions in the gastric fornix and corpus (Fig. 4A-C) 

- Flat to slightly elevated reddish areas were also identified in the fornix, cardia, and corpus (Fig. 4D)

- Corpus-predominant atrophy (Fig. 4E and 4F) 

Figure 4. Endoscopic images of Case 2 at the age of 47 years. Scattered minute whitish protrusions in the gastric fornix and corpus (A-C, arrow; A, white light image; B, magnifying observation after indigo carmine dye spraying; C, magnifying observation with narrow band imaging). A slightly elevated, reddish area was identified in the corpus (D). Mucosal atrophy was more prominent in the corpus (E) than in the antrum (F). 

* Pathology (reddish area): linear endocrine cell hyperplasia (Fig. 5)

Figure 5. Pathological images of Case 2. Biopsy from the stomach revealed linear endocrine cell hyperplasia that is positive for chromogranin A and synaptophysin. A, hematoxylin and eosin stain; B, chromogranin A stain; C, synaptophysin stain. 

* Serologic test:

- Anti-parietal cell antibodies (positive), Intrinsic factor antibodies (negative)

- Pepsinogen I (28.7 ng/mL, borderline low)

- Pepsinogen I/II ratio (1.1, low)

 

<Discussion>

* Multiple small, white lesions in the gastric mucosa (white globular appearance)

: Pathology - Dilated glands containing eosinophilic materials with necrotic epithelial fragments called intraglandular necrotic debris (cystic dilatation of the gastric glands containing mucus)

: PPI or P-cab 사용시에도 나타나게 되어, 병변이 관찰되면 AIG인지 PPI 사용에 의한 점막 병변 여부를 확인해 봐야 한다.


In conclusion, we present two patients with autoimmune gastritis. Although autoimmune gastritis had not been recognized over years of endoscopic monitoring in these two patients, the presence of scattered minute whitish protrusions in their gastric mucosa finally prompted further investigations, which ultimately led to the correct diagnosis of autoimmune gastritis. These cases indicate that understanding, awareness, and recognition of the endoscopic features specific to autoimmune gastritis are important for the prompt diagnosis of this disease.


<Abstract>

Herein, we report two patients with autoimmune gastritis who had undergone multiple esophagogastroduodenoscopy procedures for 17 and 9 years, respectively, before their diagnosis. Instead, they had been diagnosed with and treated for Helicobacter pylori-associated gastritis. The correct diagnosis was made when scatterings of tiny whitish protrusions in the gastric mucosa were detected on esophagogastroduodenoscopy. Our findings suggest that scattered tiny whitish bumps may be a clue to the diagnosis of autoimmune gastritis

Key words: autoimmune gastritis, esophagogastroduodenoscopy, scattered lesions, small white protrusions, mucosal lesions

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대한자가면역성위염연구회

주소 : 경기도 용인시 기흥구 중부대로 579, 508-23호 (구갈동, 강남대프라자)

대표전화 : 070-8080-0453  이메일 : autogastritis@gmail.com 


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